142 Old Mill Rd DAVIE COMITY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVDIENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAMEyh t \ AR\ems PROPERTY ADDRESS DI LV m.II yj •Z 7d D I DATE 'I h -14
LOCATION I �� cb Q r Tv� p
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE C1S4 # BEDROOMS , # BATHS »l # OCCUPANTS —C GARBAGE DISPOSAL: Yes'
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOFt.E/SHIFT # SEATS INDUSTRIAL WASTE`:;Yes/No
LOT SIZE •�b.[Aib TYPE WATER SUPPLY V9A' , DESIGN`WASTEWATER FLOW (GPD) NEW SITE ,REPAIR SITE V
SYSTEM SPECIFICATIONS: TANK SIZE 100
GAL,, PUMP TANK BAL. TRENCH WIDTH 43 , ROCK DEPTH �a LIMBAR FT. W I
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OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:" = M
***THIS PERMIT ISK-SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER'SYSTEM CONTRACTOR MUST='
SEE THIS PERMIT BEFORE INSTALLINq.THE SYSTEM. -
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IMPROVEMENT PERMIT BY
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY
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AUTHORIZATION NO. O Li 21 OPERATION PERMIT BY DATE 1
**THE ISSUANCE OF THIS OPERATION PERMIIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 'SEWAGE TREATMENT AND DISPOSAL. SYSTEMS', BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTOPILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 10/95
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT >
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
,System. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME � '(�c� � A�.`�e� PROPERTY ADDRESS _ ILV I►1 �I ��Y � 7d 0� DATE. -I b-11,
LOCATION 1 '57, i d r Nib
C�\ .+ J.
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yesw
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL'WASTEr.Yes/No
LOT SIZE c-tAta TYPE WATER SUPPLY W NO, DESIGN WASTEWATER FLOW (GPD) NEW SITE •'REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE I� GAL.' PUMP TANK GAL. TRENCH WIDTH � � ROCK DEPTH f� � LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:` '
***THIS PERMIT ISrSUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING,THE SYSTEM.
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IMPROVEMENT PERMIT BY � �'` .v • :=,_a
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FJNAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:N-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704)0634-8760.
OPERATION PERMIT SYSTEM INSTALLED BYy.;�ss�
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AUTHORIZATION N0. U -...DPERATION;PERMIT BY DATE
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL.3NDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE'TREATMENT AND DISPOSAL. SYSTEMS", BUT SMALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM HILL FUNCTION SATISFACTORILY FOR'ANY GIVEN PERIOD OF TIME.
�DCHD 10/95 „'
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
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P.D. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued.in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must be issued by the Davie County Environmental Health-Section prior to
issuance of any Building Permits. This Fore/Authorization Number should be presented to the Davie County"Building Inspections
Office�w-h-e�nn applying for Building Permits.***
NAME 1 C•� A k DATE - 1b — 7 AUTHORIZATION NUMBER
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION O 1` 1�
CON ENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
fffNOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD OF FIVE (5) YEARS.
ENVIRONMENTAL HEALTH SPECIALIST / DATE;
DCHD 10/95
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME ��c l�A (2 'Q PHONE NUMBER
ADDRESS d� d ��\ \, R� SUBDIVISION NAME
-0z LOT#
DIRECTIONS TO SITE e -� 4T-
C ��ta
1146 �J
DATE SYSTEM INSTALLED rAg t,,nfNAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED -1
TYPE WATER SUPPLY_ \QSL SPECIFY PROBLEM OCCURRING n.satc�
1
DATE REQUESTED_ rI _ I C� INFORMATION TAKEN BY
This is to certify that the information provided Is correct to the best of my know!I
.!_qland that I and stand I am responsible for charges i curved from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev.1/93